Necessity is the mother of invention: an innovative hospitalist-resident initiative for improving quality and reducing readmissions from skilled nursing facilities.

: Hospital readmissions have been a major challenge to the US health system. Medicare data shows that approximately 25% of Medicare skilled nursing facility (SNF) residents are readmitted back to the hospital within 30 days. Some of the major reasons for high readmission rates include fragmented information exchange during transitions of care and limited access to physicians round-the-clock in SNFs. These represent safety, quality, and health outcome concerns. : The goal of the project was to reduce hospital readmission rates from SNFs by improving transition of care and increasing physician availability in SNFs (five to seven days a week physical presence with 24/7 accessibility by phone). : We proposed a model whereby a hospitalist-led team, including the resident on the geriatrics rotation, followed patients discharged from the hospital to one SNF. Readmission rates pre- and post-implementation were compared. : The period between January 2014 and June 2014 served as the baseline and showed readmission rate of 32.32% from the SNF back to the hospital. After we implemented the new hospitalist SNF model in June 2014, readmission rates decreased to 23.96% between July 2014 and December 2014. From January 2015 to June 2015, the overall readmission rate from the SNF reduced further to 16.06%. Statistical analysis revealed a post-intervention odds ratio of 0.403 (p < 0.001). : The government is piloting several care models that incentivize value- based behavior. Our study strongly suggests that the hospitalist-resident continuity model of following patients to the SNFs can significantly decrease 30-days hospital readmission rates.